Whilst, I think there is a lot to agree with in this post, I’m troubled by much of it. My background is working in digital (some of it with the NHS) but I also am a patient with a long-term condition.

IMHO too much digital healthcare is designed around the “otherwise well” – healthy people who occasionally need to access healthcare because of a temporary problem. And yes, that is a large proportion of the population, but they make up quite a small proportion of the usage of the health system (a classic 20/80 split). So whilst there is value in designing services that support them, extrapolating those services to the majority of healthcare users is problematic.

The main concerns I have with the argument for non-geographic GP services is that (a) it reduces the notion of healthcare to a series of transactions, (b) it ignores the importance of place that speaks to a large part of the population and (c) it silos GPs as standalone from the plethera of primary/community health services that support individuals and population health management.

If we take “care” to mean “someone else is bothered by my predicament” (my favourite defintion), then no algorithm can replace human interaction. Moreover, being put in a front of someone because they have the right qualifications is secondary to being put in front of someone you trust and value the relationship that you have with them. That trust comes from regular contact; but it also comes from shared experience: we’re in this together. If I’m after an oinment for a rash, then maybe that’s not an issue, but if my cancer has returned and I’m worried how I’m going to cope financially and mentally with caring for my disabled son whilst going through another round of chemo, then do I want to be shouting down a Zoom call in the kitchen hoping the kids don’t come in? I probably want that conversation with the person (or at least team) who has also seen me through my pregnancies, helped me learn about what my son can and won’t be able to do etc etc. And I build that trust through the regular oinment for rash type appointments; in the same way the fallacy of automation works: I can only deal with an exceptional event because I’ve had the hours of learning from dealing with the regular.

And this is where the value of place comes in. Taking the David Goodhart definition of the “anywheres” vs the “somewheres”, too much digital health is designed around the “anywheres” (case in point: the priority put on designing a find a GP service, when ~50% of the population live within 2 miles of where they grew-up). The team at my GP surgery know the school/nurseries that my kids use, they know the street I live on (in our case one of the locums actually lives on it), they understand the pattern of my life. When we’ve taken our kid to the out-of-hours we’ve seen a doctor who also locums at our surgery (we haven’t yet been followed up by the same doc who saw us in OOO, but it could happen). They know the services they can refer us to, and quite possibly use them too. Similarly our pharmacist knows me well enough to know I need a flu jab, even if I don’t look like someone who should automatically get one. That stuff matters, and the intel gathered is hugely valuable for population health management.

The closest parallel I can make is the argument that we could make libraries more efficient by just giving everyone an e-Reader and offering temporary downloads via a web catalogue. Yes, the transaction might be more efficient but you completely miss the true value of a library.

So remote appointments with a random GP will work for some people; but they are a small subset of the work of the health service. Design these services to complement not replace what exists already, and work out how to transistion between them (what happens when your 20-something becomes pregnant and needs access to a range of pre-natal services etc) and how the funding will match the demand rather than a simple headcount formula.